Are we ready for the Better Medication Management System?

Over-the-Counter Codeine-from Therapeutic Use to Dependence, and the Grey Areas in Between

Codeine is a widely used analgesic, that is available for sale in pharmacies over the counter (OTC) in a number of countries including the UK, South Africa, Ireland, France and Australia. In these countries with OTC codeine sales there has been emerging concerns about misuse of and dependence on codeine containing combination analgesics, with increasing numbers of people presenting for help with codeine dependence at primary care and addiction treatment services. This has led to many countries reviewing availability of codeine in OTC available preparations, and considering possible measures to reduce harms from misuse of OTC codeine containing combination analgesics.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Diabetes, kidney disease and cardiovascular disease patients. Assessing care of complex patients using outpatient testing and visits: additional metrics by which to evaluate health care system functioning

BACKGROUND

The triad of cardiovascular disease (CVD), chronic kidney disease (CKD) and diabetes mellitus (DM) share many fundamental disease pathways. Patients with these conditions contribute excessively to health care costs. Opportunities for system redesign require metrics by which to evaluate the impact.

METHODS

Using a provincial comprehensive set of administrative billing databases (outpatient visits, laboratory tests, pharmacy and hospital inpatient services), we itemized the prevalence of each and combination of conditions, resource utilization associated with each condition and combinations, using ICD 9-10 billing codes and standard definitions. Three consecutive years (2003-2005) were used to establish stability of findings.

RESULTS

CKD, CVD and DM diagnoses are found in 422 124 persons within a province of 4.3 million individuals (10%); 1.7% had all three conditions. The median age of each cohort varied significantly between those with multiple conditions (67-79 years) versus those with single condition (56-72 years). The median number of physician visits was 26 per patient year. Duplicate testing accounted for expenditures of $3 million/annum; 7.55% of patients accounted for 34.4% of duplicate tests. Those with DM or CKD had similar use of medications, physician visits and hospital days. Those with all conditions (CVD-CKD-DM) had a median of 6 in-hospital days/year. A significant proportion were not on ACE/ARB or statin medications (30 and 45%, respectively).

CONCLUSION

Patients with chronic, complex conditions consume a large number of outpatient and inpatient resources. Documenting these allows identification of a set of metrics by which to design and measure health care system redesign initiatives. Potential targets to benchmark in designing more effective systems have been identified.

Just what the doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication errors

OBJECTIVE

To examine the association between computerization of physician orders and prescribing medication errors. Data Sources. Studies published in English language were identified through MEDLINE (1990 through December 2005), Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles. Of 252 identified in the search, 12 (4.8 percent) original investigations that compared rates of prescribing medication errors with handwritten and computerized physician orders were included.

DATA COLLECTION

Information on study design, participant characteristics, clinical settings, and outcomes rates were abstracted independently by two investigators using a standardized protocol.

PRINCIPAL FINDINGS

Compared with handwritten orders, 80 percent of studies (8/10 studies) reported a significant reduction in total prescribing errors, 43 percent in dosing errors (3/7 studies), and 37.5 percent in adverse drug events (3/8 studies). The use of computerized orders was associated with a 66 percent reduction in total prescribing errors in adults (odds ratio [OR]=0.34; 95 percent confidence interval [CI] 0.22-0.52) and a positive tendency in children (p for interaction=.028). The benefit of computerized orders was larger when the rate of errors was more than 12 percent with handwritten orders (p for interaction=.022). Significant heterogeneity in the results compromised pooled relative risks. One randomized controlled intervention demonstrated the greatest benefits of computerized orders on total prescribing errors (OR=0.02, 95 percent CI 0.01-0.02) and dosing errors (OR=0.28; 95 percent CI 0.15-0.52) with 775 avoided prescribing errors (95 percent CI 752-811) per 1,000 orders in a pediatric hospital.

CONCLUSIONS

Computerization of physicians' orders shows great promise. It will be more effective when linked to other computerized systems to detect and prevent prescribing errors.

Clinical prediction rules for bacteremia and in-hospital death based on clinical data at the time of blood withdrawal for culture: An evaluation of their development and use

RATIONALE, AIMS AND OBJECTIVES

To develop clinical prediction rules for true bacteremia, blood culture positive for gram-negative rods, and in-hospital death using the data at the time of blood withdrawal for culture.

METHODS

Data on all hospitalized adults who underwent blood cultures at a tertiary care hospital in Japan were collected from an integrated medical computing system. Logistic regression was used for developing prediction rules followed by the jackknife cross validation.

RESULTS

Among 739 patients, 144 (19.5%) developed true bacteremia, 66 (8.9) were positive for gram-negative rods, and 203 (27.5%) died during hospitalization. Prediction rule based on the data at the time of blood withdrawal for culture stratified them into five groups with probabilities of true bacteremia 6.5, 9.6, 21.9, 30.1, and 59.6%. For blood culture positive for gram-negative rods, the probabilities were 0.6, 4.7, 8.6, and 31.7%, and for in-hospital death, those were 6.7, 15.5, 26.0, 35.5, and 56.1%. The area of receiver operating characteristic for true bacteremia, blood culture positive for gram-negative rods, and in-hospital death were 0.73, 0.64, and 0.64, respectively, in original cohort and 0.72, 0.64, and 0.64 in validation respectively.

CONCLUSIONS

The clinical prediction rules are helpful for improved clinical decision making for bacteremia patients.

Adverse drug events in general practice patients in Australia

OBJECTIVE

To investigate the frequency, cause, and severity of adverse drug events (ADEs) among general practice patients.

DESIGN

Between May 2003 and February 2004, a subsample of 282 general practitioners in the BEACH (Bettering the Evaluation And Care of Health) data collection program recorded patient responses to questions about ADEs.

MAIN OUTCOME MEASURES

Frequency, cause, and severity of ADEs; and frequency of hospitalisation and proportion of events that were preventable.

RESULTS

From 8215 encounters, GPs reported that 852 patients (10.4%) had experienced an ADE in the previous 6 months. Patients aged over 45 years (versus under 45 years), children aged 1-4 years (versus older children), and female patients (versus male patients) were significantly more likely to have experienced an ADE. Most patients (83.5%) had experienced only one ADE, with 10.7% and 5.8% experiencing two and three or more events, respectively. For 71.9% of patients, one reason for the most recent event was a recognised side effect, followed by drug sensitivity (12.4%) and allergy (11.0%). Over half of patients were rated as having a "mild" event, with 35.8% rated as "moderate", and 10.0% as "severe". GPs classified 23.2% of events as preventable, and 7.6% of events resulted in hospitalisation.

CONCLUSION

Our study reveals the high frequency of ADEs in patients attending general practice. This level of morbidity makes ADEs one of the most significant causes of morbidity in the Australian community.